Friday, August 28, 2009

Army, NIMH Search for Causes of Soldier Suicide Crisis

Psychiatr News August 21, 2009
Volume 44, Number 16, page 1
© 2009 American Psychiatric Association


Professional News

Army, NIMH Search for Causes of Soldier Suicide Crisis
Aaron Levin
The startling increase in the number of suicides by members of the U.S. Army in the last few years prompts a major collaborative study of risk and protective factors.

The National Institute of Mental Health (NIMH) has tapped a consortium of four research universities to investigate risk and protective factors influencing a troubling increase in suicides in the U.S. Army.

The number of suicides by U.S. soldiers has risen steadily in recent years until levels have equaled those among comparable civilians, who historically have had higher rates. Responding to concern from Congress, the public, and Pentagon officials, the Army allotted $50 million to NIMH for the new study, whose goal is to "provide a science base for effective and practical interventions to reduce suicide rates and address associated mental health problems," according to an NIMH statement.

Such large, longitudinal studies that look at risk and protective factors are unusual in military populations, said Robert Heinssen, Ph.D., acting director of the Division of Services and Intervention Research at NIMH. But the study is unlikely to come up with a single cause for military suicides, he told Psychiatric News.

"[The researchers] are really searching for likely, but weakly linked, risk factors that in combination might create different risk states over time," he said.

The new study will draw on soldiers' personnel and health records and will survey several hundred thousand current soldiers and incoming recruits over the next five years.

The Army now investigates every suicide within the service. It began issuing public reports in 2007 and stated that failed marital or other relationships were most strongly associated with suicide (Psychiatric News, September 21, 2007).

Robert Ursano, M.D., director of the Center for Traumatic Stress Studies at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., where he also chairs the Department of Psychiatry, will direct the project, the largest ever military study of suicide and mental health.

"This is a unique joining of the Department of Defense and the NIMH to address an issue of national security that will also build tools with peacetime implications," Ursano told Psychiatric News.

His principal collaborators will each add a different area of expertise to USUHS's familiarity with military epidemiology. Stephen Heeringa, Ph.D., of the University of Michigan's Institute for Social Research has experience in securely handling large datasets. Ronald Kessler, Ph.D., of Harvard Medical School is a leading psychiatric epidemiologist, while Columbia University's J. John Mann, M.D., has extensively studied the neurobiology of suicide and the use of the psychological autopsy to examine factors leading up to the event.

The study is a collaborative research project grant, NIMH's term for projects in which the government takes a direct interest beyond routine management, said Heinssen in an interview.

"Two NIMH scientific officers—a psychiatric epidemiologist and a mental health services researcher—will participate as investigators, working on ways to integrate data from surveys with the data the Army routinely collects," said Heinssen.

Several researchers with military backgrounds are also involved in the project, including psychiatric epidemiologist Col. Charles Hoge, director of the Division of Psychiatry and Behavioral Sciences at Walter Reed Army Institute of Research in Silver Spring, Md., and Col. Charles Engel, assistant chair of the Department of Psychiatry at USUHS.

Former APA President Paul Appelbaum, M.D., the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Psychiatry, Law, and Ethics at the Department of Psychiatry at Columbia University College of Physicians and Surgeons, will chair the project's ethics committee, which faces two primary challenges in a study of military populations: confidentiality of information and voluntariness of consent to protect soldiers from coercion and undue influence.

Four Sources Will Be Tapped

Study data will come from four main sources, beginning with the Army's massive existing records on service personnel. Researchers will also survey 90,000 current service members, including those from the National Guard and Reserves, asking about risk and protective factors, as well as about suicidal ideation and attempts. The 80,000 to 120,000 recruits who join the Army in each of the study's first three years will be asked to complete a similar survey.

Study investigators will also set up a case-control study matching soldiers who attempted or completed suicide in recent years with demographically similar controls.

The project may be analogous to another long-term study of disease-influencing factors.

"The Framingham heart study looked at the roles of lifestyle, behavioral characteristics, and biological functions and came up with a good algorithm for stroke and heart attack," said Heinssen. "With that information, the risk factors in cardiovascular disease became targets for treatment."

Key Results to Get Early Release

The new study will look for and evaluate several personal and community factors that might influence the risk for suicide, including combat exposure, overseas deployments, and unit cohesion. It will also consider intermediate outcomes such as posttraumatic stress disorder, depression, anxiety, divorce, family violence, and substance abuse. An "adaptive survey design" will permit investigators to alter survey questions if necessary to provide more data.

The investigators will not wait to complete the study before passing along any useful results.

"Real-time information can allow the leadership to respond quickly and allocate resources for prevention," said Ursano.

The study will provide unpublished interim reports to the Army every six months over the five-year life of the project. However, researchers may present results through normal peer-reviewed channels in print or at scientific conferences as results reach meaningful levels, said Heinssen.

At least one long-time student of suicide hopes the researchers will look beyond proximate causes.

"I applaud the effort, but they may have to go back earlier in life to find vulnerabilities to suicidal behavior," said Mark Kaplan, Dr.P.H., a professor of community health at Portland State University in Oregon.

Suicide is a rare and complex phenomenon, said Kaplan in an interview. The inevitable access of soldiers to weapons and the desensitization to killing of military training and combat make it simpler for an unhappy soldier to impulsively take his own life, but stoicism and difficulty articulating emotions that are part of American masculine culture are contributing factors too, he said.

Nevertheless, the knowledge gained by the study may be generalizable to broader populations, said another civilian expert.

"I believe it is exciting and a very comprehensive approach to understanding the problems that lead to suicide in the adult population," said psychiatrist Paula Clayton, M.D., medical director of the American Foundation for Suicide Prevention. "I'm grateful to the service for recognizing a problem that needs investigating and for funding this study."

The NIMH press release on the study is posted at .
Army, NIMH Search for Causes of Soldier Suicide Crisis

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